Full Job Description
About Us
Mass General Brigham’s Population Health team is focused on providing resources and offerings to consumers that improve their overall health care experience, engages them in their care, and is affordable. We develop products and programs to provide consumers with what they want when they want it. This consumer-first model provides health care that is tailored to each individual. By leveraging innovative technologies and methods, our value-based care models support the needs of the whole patient, no matter how complex.
This is an exciting opportunity to join the Mass General Brigham Population Health department to care for patients with Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD). The Population Health department is developing a Multidisciplinary Chronic Kidney Disease (CKD) Program to proactively identify and manage patients in risk contracts (primarily Medicare Shared Savings Program) across the health system with kidney disease. The program goals are to ensure the following key elements:
- Appropriate and timely identification of individuals at risk for progressive CKD
- Evidence-based, timely clinical evaluation
- Comprehensive patient education
- Coordination of care including review of treatment options, and ensuring a seamless CKD to ESRD transition (avoiding hospitalization when possible)
- Timely referral for transplant evaluation for patients with more advanced CKD
The Opportunity
We are seeking a highly skilled, dedicated, and compassionate Advanced Practice Provider (APP) with expertise in Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) management to join our dynamic team. The APP will see patients in multiple outpatient clinics, primarily at BWH and NWH initially.
The APP will work in a collaborative and patient-centric environment, contributing to the delivery of high-quality healthcare services. Primary responsibilities include clinical assessment, evidence-based kidney disease management, oversight of anemia management, CKD education and goals and values discussions with patients and coordination of care to mitigate unnecessary utilization of care.
Additionally, the APP will be responsible for:
- Clinical insight for the development, implementation, and operation of the CKD Program
- Direct patient care and education to patients with advanced chronic kidney disease
- Clinical oversight of the day-to-day functions of the Multidisciplinary CKD program, including the refinement of protocols, procedures and policies
- Support for all clinical needs of the CKD Care Coordinator(s) who report to the program manager
- Implementation of the Multidisciplinary CKD Program at selected assigned practice site(s)
- Reviewing data, in collaboration with program leadership, and providing input and insights on patient and program performance (this will include review of the data related to utilization and total cost of care)
- Providing comprehensive patient care in alignment with the Nephrology clinical team and in accordance with the nursing process and practice standards
- Proactively identifying patients in risk contracts (initial primary focus being Medicare Shared Savings Program) across the health system with kidney disease who may benefit from co-management support
- Supporting and coordinating patients’ transition from CKD to ESRD with comprehensive education, including a review of kidney failure treatment options and renal replacement therapy modalities
- Overseeing interventions and plans based on assessment and protocols under the direction of, and in consultation/collaboration with, a supervising physician
- Documenting all assessment data, orders, interventions, results and evaluations within the patient’s medical record per established standards
- Evaluating and analyzing the patient’s response to therapeutic interventions
- Providing information, education, and support to patients and families in a way that includes them in the plan of care
- Eliciting goals and values from patients and care partners to better guide them in chronic disease care plans
- Clinically reviewing referrals into the Multidisciplinary CKD program for appropriateness of enrollment
- Coordinating nursing care activities in collaboration with other members of the interdisciplinary team to facilitate achievement of patient goals
- Reviewing and manage patients with anemia in the outpatient setting
- Ensuring medications are administered safely in accordance with professional standards of practice and nursing policies and procedures
- Assisting in completion of patient/insurance paperwork as needed
Location & Schedule
We are seeking a full-time, 40-hour APP. This is a day shift position (Monday-Friday, 8:00 AM to 4:00 PM or 9:00 AM to 5:00 PM). There is no nights, weekends, holidays, or on-call required. The weekly schedule will consist of 36 hours of clinical, patient-facing time and 4 hours of administrative time. This will be a hybrid role starting with 4 days of in-person per week at both Brigham & Women’s Hospital and Newton-Wellesley Hospital sites. There is a possibility of moving to 3 days of in-person work and 2 days of remote work in the future depending on program development.
Qualifications
Education:
- Required: Master’s degree in nursing or physician assistant studies
License/Certification:
- Required: Certified Massachusetts Nurse Practitioner or Physician Assistant licensure
- Required: BLS certification
Experience:
- Preferred: 3+ years of experience in clinical nephrology
EEO Statement
Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.